Encephalitis Assessment and Nursing Diagnosis

Encephalitis is an infection of the central nervous system caused by viruses or other microorganisms, which cause strong lymphocytic infiltration in brain tissue and leptomeninges cause cerebral edema, brain ganglion cell degeneration and destruction of nerve cells diffusion (Anania, 2008). Encephalitis is an inflammation of the brain tissue that can be caused by bacteria, worms, protozoa, fungi, rickets, or viruses (Mansjoer, 2000)

Although the cause is different, the clinical symptoms of encephalitis is more or less the same and distinctive, so that it can be used as diagnostic criteria. Generally, the symptoms include fever, convulsions and decreased consciousness. (Mansjoer, 2000).

Signs and symptoms of encephalitis as follows:

1. Sudden temperature rises, often found hyperpyrexia.
2. Consciousness quickly dropped.
3. gag.
4. Seizures, which can be general, focal or twitching only.
5. Other cerebral symptoms, which may occur individually or together, eg paresis or paralysis, aphasia, and so on.

Assessment

Data that needs to be examined include (Doenges, 1999):

1. Biodata.
Biodata is the identity of the clients includes: name, age, gender, religion, ethnicity, address, date of hospital admission, registration number, date of assessment and medical diagnostics. This identity is used to differentiate clients from one another.

2. Main complaint.
The main complaint is the need to encourage clients to enter the hospital. The main complaints in patients with encephalitis include headaches, neck stiffness, impaired consciousness, fever and seizures.

3. History of present illness.
A history of current clients which include complaints, the nature and great complaints, start or recurrence of disease ever experienced before. Usually the prodromal period lasts between 1-4 days, characterized by fever, headache, dizziness, vomiting, sore throat, malaise, pain in the extremities and pale. Followed by signs of encephalitis that the severity depends on the distribution and extent of the lesion in neurons. The symptoms such as anxiety, irritable, screaning attack, behavioral changes, impaired consciousness and convulsions sometimes with focal neurological signs such as aphasia, hemiparesis, hemiplegia, ataxia and paralysis of the nerves of the brain.

4. History of pregnancy and birth.
In this case studied, among others; a history of prenatal, natal and post natal. In prenatal history should note any disease ever suffered by the mother primarily infectious diseases. History of childbirth need to know whether the baby is born in the gestational age at term or not, because it affects the immune system against the disease in children. The trauma of childbirth also affect the incidence of diseases for example; amniotic fluid aspiration in children. History of post childbirth is necessary to know the state of the child after birth. Example: low birth weight, and Apgar score.

5. P6. revious medical history.
Contact or relationship with meningitis cases will increase the likelihood of inflammation or infection of the brain tissue. Immunizations need to be studied to determine how the child's immune system. Allergies in children need to know to be avoided because it may make things worse.

6. Family health history.
Is a picture of the health of the family, whether there is a relationship with the illness. In this situation the health status of families need to know, if there are family members who suffer from infectious diseases in connection with the disease experienced by the client (Soemarno marram, 1983).

7. Social history.
Environment and the child's family is very supportive to the growth and development of children. Traveling clinic of the disease so disturbing mental status, behavior and personality. Nurse charged assess the status of the client or family in order to prioritize the issue in treatment.

8. Basic Needs (daily activities).
In patients with encephalitis often disruption of daily habits, among others: the fulfillment of nutritional disorders because of nausea, vomiting, hypermetabolic due to infectious processes, and increased intracranial pressure. Rest patterns in patients with frequent seizures, it greatly affects the patient. Pattern personal hygiene should be practiced on the bed because the patient is weak or unconscious, and is likely to depend on others, play behavior is unknown if any changes need to know as a result of hospitalization in children.


Nursing Diagnosis for Encephalitis

1. Hyperthermia r / t the disease: infection.
2. Nausea r / t increased intracranial pressure, inflammation of the brain.
3. Disturbed Sensory Perception (type: visual, auditory, kinesthetic, tactile, olfactory) r / t biochemical imbalances.
4. Risk for trauma r / t reduction in muscle coordination.